Basic Information
| Provider Information | |||||||||
| NPI: | 1063479962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIDDLEMAS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | O. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 HODGES DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504315714 | ||||||||
| FaxNumber: | 8504316403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 HODGES DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504315714 | ||||||||
| FaxNumber: | 8504316403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME12392 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 050341 | 01 | FL | VISTA | OTHER | 3555770001 | 05 | FL | MEDICAID | 37148 | 01 | FL | BC/BS | OTHER |